Memo Clarifies CMS Guidelines on Injectables

July 1, 2002

Injectable drugs should be covered by Medicare if beneficiaries administer them less than 50 percent of the time, according to a clarification on this issue by the Centers for Medicare and Medicaid services that's set to take effect Aug. 1.

The clarification aims to resolve CMS's ambiguity on injectable drugs. It came in a memo to regional private contractors that process Medicare claims, instructing them to reimburse users of the multiple sclerosis drug, Avonex, because it generally is not self-administered.

Until recently, Medicare has paid only for injectable drugs administered in a doctor's office, but not drugs that patients administer themselves.

Last year, Congress ruled that Medicare should cover injectables that are "not usually self-administered," but neglected to define the term "not usually."

As a result, Medicare contractors made different reimbursement decisions for the same drug.